Provider Demographics
NPI:1780629469
Name:MARCHETTI, JASON MARC (MD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MARC
Last Name:MARCHETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W CAMPBELL RD STE 7
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3357
Mailing Address - Country:US
Mailing Address - Phone:469-307-5109
Mailing Address - Fax:888-417-4939
Practice Address - Street 1:546 E SANDY LAKE RD
Practice Address - Street 2:STE 250
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-5791
Practice Address - Country:US
Practice Address - Phone:469-307-5109
Practice Address - Fax:888-417-4939
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7470208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D5683Medicare PIN
TX8F7791Medicare PIN
TXI31269Medicare UPIN
TX1810160-01Medicaid
TX8D5684Medicare PIN